§ 4901 — Reporting requirements for utilization review agents

§ 4901. Reporting requirements for utilization review agents. (a)\nEvery utilization review agent shall biennially report to the\nsuperintendent of financial services, in a statement subscribed and\naffirmed as true under the penalties of perjury, the information\nrequired pursuant to subsection (b) of this section.\n (b) Such report shall contain a description of the following:\n (1) The utilization review plan;\n (2) Those circumstances, if any, under which utilization review may be\ndelegated to a utilization review program conducted by a facility\nlicensed pursuant to article twenty-eight of the public health law or\npursuant to article thirty-one of the mental hygiene law;\n (3) The provisions by which an insured, the insured's designee, or a\nhealth care provider may seek reconsideration of or appeal from adverse\ndeterminations by the utilization review agent, in accordance with the\nprovisions of this title, including provisions to ensure a timely appeal\nand that an insured, the insured's designee, and, in the case of an\nadverse determination involving a retrospective determination, the\ninsured's health care provider is informed of their right to appeal\nadverse determinations;\n (4) Procedures by which a decision on a request for utilization review\nfor services requiring preauthorization shall comply with timeframes\nestablished pursuant to this title;\n (5) A description of an emergency care policy, which shall include the\nprocedures under which an emergency admission shall be made or emergency\ntreatment shall be given;\n (6) A description of the personnel utilized to conduct utilization\nreview including a description of the circumstances under which\nutilization review may be conducted by:\n (i) administrative personnel;\n (ii) health care professionals who are not clinical peer reviewers;\nand\n (iii) clinical peer reviewers;\n (7) A description of the mechanisms employed to assure that\nadministrative personnel are trained in the principles and procedures of\nintake screening and data collection and are appropriately monitored by\na licensed health care professional while performing an administrative\nreview;\n (8) A description of the mechanisms employed to assure that health\ncare professionals conducting utilization review are:\n (i) appropriately licensed, registered or certified; and\n (ii) trained in the principles, procedures and standards of such\nutilization review agent.\n (9) A description of the mechanisms employed to assure that only a\nclinical peer reviewer shall render an adverse determination;\n (10) Provisions to ensure that appropriate personnel of the\nutilization review agent are reasonably accessible by toll-free\ntelephone:\n (i) not less than forty hours per week during normal business hours,\nto discuss patient care and allow response to telephone requests, and to\nensure that such utilization review agent has a telephone system capable\nof accepting, recording or providing instruction to incoming telephone\ncalls during other than normal business hours and to ensure response to\naccepted or recorded messages not less than one business day after the\ndate on which the call was received; or\n (ii) notwithstanding the provisions of subparagraph (i) of this\nparagraph, not less than forty hours per week during normal business\nhours, to discuss patient care and allow response to telephone requests,\nand to ensure that, in the case of a request submitted pursuant to\nsubsection (a) of section four thousand nine hundred three of this title\nor an expedited appeal filed pursuant to subsection (b) of section four\nthousand nine hundred four of this title, on a twenty-four hour a day,\nseven day a week basis;\n (11) The policies and procedures to ensure that all applicable state\nand federal laws to protect the confidentiality of individual medical\nand treatment records are followed;\n (12) A copy of the materials to be disclosed to an insured or\nprospective insured pursuant to sections three thousand two hundred\nseventeen-a or four thousand three hundred twenty-four of this chapter,\nwhichever is applicable, and this title;\n (13) A description of the mechanisms employed by the utilization\nreview agent to assure that all subcontractors, subvendors, agents or\nemployees affiliated by contract or otherwise with such utilization\nreview agent will adhere to the standards and requirements of this\ntitle; and\n (c) The clinical review criteria and standards contained within the\nutilization review plan shall not be subject to disclosure pursuant to\nthe provisions of article six of the public officers law.\n